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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425325
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:18:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230503095914
FACILITY NAME:CHANTILLY LACE MANORFACILITY NUMBER:
366425325
ADMINISTRATOR:TERESA BADDELEYFACILITY TYPE:
740
ADDRESS:7421 MINSTEAD AVETELEPHONE:
(760) 552-9980
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 5DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Teresa Baddeley, LicenseeTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Uncleared staff are working at the facility.
Facility staff are not receiving adequate training.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with caregiver Jeannene Regets and explained the purpose of the visit. Licensee was notified of this complaint and arrived at the facility approximately 10 minutes later. The investigation included a facility tour, file reviews, and interviews with relevant parties.

Allegation #1: “Uncleared staff are working at the facility”. The allegation alleged that multiple employees at the facility do not have a background check. LPA Nickolas’ interview with the Licensee revealed that all employees have a criminal records clearance. LPA Nickolas’ file review revealed that all employees have a criminal record clearance with our agency. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #2: “Facility staff are not receiving adequate training”. The allegation alleged that only one (1) day of training is provided at the facility. LPA Nickolas' interview with staff #1 (S1) revealed that they conduct a lot of the training at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20230503095914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: CHANTILLY LACE MANOR
FACILITY NUMBER: 366425325
VISIT DATE: 05/09/2023
NARRATIVE
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S1 stated that any employees hired within the last year have received training before working with clients. LPA Nickolas' interview with staff #2 (S2) revealed they were trained before working with clients. S2 stated that they feel safe performing their job duties with the training received. LPA Nickolas' interview with the Licensee revealed that new employees are provided the recommended training outlined by the Title 22 California Code of Regulations (CCR). LPA Nickolas randomly audited four (4) out of six (6) employees' training records, which revealed that employees are provided 40 hours of training within 30 days of hire. LPA Nickolas' file audit also revealed that the facility provides all employees with 20 hours of annual training. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230503095914

FACILITY NAME:CHANTILLY LACE MANORFACILITY NUMBER:
366425325
ADMINISTRATOR:TERESA BADDELEYFACILITY TYPE:
740
ADDRESS:7421 MINSTEAD AVETELEPHONE:
(760) 552-9980
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 5DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Teresa Baddeley, LicenseeTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility staff records are incomplete.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with caregiver Jeannene Regets and explained the purpose of the visit. Licensee was notified of this complaint and arrived at the facility approximately 10 minutes later. The investigation included a facility tour, file reviews, and interviews with relevant parties.

The allegation alleged that the facility's employees had no CPR training and tuberculosis (TB) tests. LPA Nickolas' interview with the Licensee revealed that all employees must have provided proof of CPR training and TB test before working at the facility. LPA Nickolas' file review revealed that all employees have proof of CPR training on file. LPA Nickolas' file review revealed that only one (1) employee has proof of TB tests on file. LPA Nickolas' file review revealed that all other employees working at the facility do not have proof of their TB tests.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20230503095914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: CHANTILLY LACE MANOR
FACILITY NUMBER: 366425325
VISIT DATE: 05/09/2023
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230503095914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CHANTILLY LACE MANOR
FACILITY NUMBER: 366425325
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2023
Section Cited
CCR
87411(f)
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87411 Personnel Requirements - General (f)

All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening...
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The Licensee shall submit proof of health screenings on all employees by the POC due date.
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This requirement was not met as evidenced by:

Based on file review, the licensee did not ensure to maintain health screenings on file, which poses a potential health, safety, personal rights violation to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5